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Does Medicare Cover Emergency Room Visits?
Yes, Medicare covers emergency room visits in a wide variety of circumstances. Medicare Part B covers emergency room visits for sudden illness, injuries, or other conditions that require immediate attention. You will be responsible for your deductible, copay, and coinsurance. Medicare will generally pay 80% of your emergency room visit cost, and you’ll pay the remaining 20%.
If you’re admitted to the hospital from the emergency room, Medicare Part A should cover your inpatient treatment. In some situations, patients with Medicare Advantage may see additional benefits for ER visits, such as a set copay or even a waived copay.
Table of Contents
Emergency Room Care a Priority For Older Adults
Emergency room visits are a medical necessity for many older adults, including Medicare beneficiaries. Unintentional falls caused the deaths of more than 64% of U.S. adults over age 65 in 2018 and remain a leading cause of emergency room visits for older adults on Medicare in 2023. Other common reasons include chest pain or stroke, car accidents, and heat-induced exhaustion.
Medicare Part A and Part B, also called original Medicare, works together to cover every aspect of emergency services for all beneficiaries. Older adults on Medicare can rest assured they have coverage for needs that may arise from visiting the ER, outpatient care, prescription drugs, and hospital services.
How Medicare Covers Emergency Room Visits
Emergency services may be covered by Medicare Part A or Part B, depending on the nature of the visit. While broad coverage in an emergency is guaranteed, it is important to understand which part covers which services, since you must meet each of your Part A and Part B deductibles before Medicare begins sharing costs for emergency services.
Coverage Criteria
For Medicare to pay for emergency room visits, beneficiaries must ensure they meet certain other criteria aside from meeting or exceeding their deductible amounts. For example, the hospital that admits the patient or provides emergency services must accept Medicare. Coverage is not guaranteed for beneficiaries who meet the criteria but visit the emergency room in a non-emergency situation.
How Medicare Part A Covers Emergency Services
Medicare Part A Pays | You Pay | |
|---|---|---|
Deductible | — | $1,600 per benefit period |
Inpatient hospital stay, including long-term hospital care: Days 1-60 | 100% of costs | — |
Inpatient hospital stay, including long-term hospital care: Days 61-90 | Remaining balance | $400 copay per day |
Inpatient hospital stay, including long-term hospital care: Days 91-150 | Remaining balance | $800 copay per day |
Inpatient hospital stay, including long-term hospital care: Days 151 and beyond | — | 100% of costs |
Medicare Part A covers inpatient hospitalization costs. Patients must be admitted to the same hospital where they visit the ER for at least two consecutive midnights to get coverage through Part A. Even if they spend the night in the ER but are not admitted to the hospital, Part B pays for their care as an outpatient.
- Inpatient hospital care: Inpatient hospital care covered under Part A includes the cost of your stay in the hospital and any treatments required therein. Coverage includes general nursing, drugs used during your stay and specific to your reason for admission, and semi-private room accommodations. Part A benefits do not cover private rooms or private nursing services.
- Long-term hospital care: Once you pay your Part A deductible, Medicare covers a hospital stay of up to 60 days at no charge. After 60 days, you must pay coinsurance, or a portion of the cost, to continue your inpatient treatment.
How Medicare Part B Covers Emergency Services
Medicare Part B Pays | You Pay | |
|---|---|---|
Deductible | — | $226 per year |
Inpatient doctor care | 80% of approved cost | 20% of approved cost, plus Part A hospital copay if applicable |
Outpatient hospital care | 80% of approved cost | 20% of approved cost, plus Part A hospital copay if applicable |
Ambulance transportation | 80% of approved cost | 20% of approved cost |
Medicare Part B covers outpatient services and routine medical care, including ambulatory care in the ER that does not require hospitalization. The following emergency services are covered under Medicare Part B.
Inpatient doctor care
Medicare Part B covers most ER costs, provided your visit does not result in you being admitted to the hospital (this is where Part A benefits would kick in). Part B pays 80% of the costs of inpatient ambulatory care provided by a doctor in the ER.
Outpatient hospital care
Part B coverage also includes care provided to you in a hospital setting as an outpatient. Examples include overnight observation assessments, x-rays, and lab tests and exclude medications you can administer yourself without the aid of a doctor.
Ambulance transportation
Emergency ambulance transportation is included under Part B benefits, but only to the nearest medical facility that can provide the care you need. Medicare covers an ambulance ride in an emergency only if riding in any other vehicle would endanger your health or you are unconscious or require medical intervention during the ride. It may also be covered if you have a written order from your doctor stating the ambulance is medically necessary.
How Medigap Covers ER Visits
Medigap offers supplemental coverage to help beneficiaries pay their Part A and Part B deductibles, copays, and coinsurance costs. You must have original Medicare in place to purchase a Medigap plan from a private insurer. Medigap may help cover your Part B deductible and the remaining 20% of ER costs that are your financial responsibility after original Medicare pays for the rest.
How Medicare Advantage Covers ER Visits
Medicare Advantage offers the same coverage as Part A and Part B, but with extras such as vision, dental, and hearing services. Beneficiaries can purchase Medicare Advantage (Part C) through a private insurer, with rates varying by location, participating facilities and doctor networks, and availability. You must have original Medicare to purchase and enroll in an Advantage plan.
Medicare Advantage plans are required by law to offer at least the same coverage for emergency room visits as original Medicare; however, the expanded benefits of many Part C plans extend to ER services. For example, many Advantage plans set a copay for ER visits, enabling beneficiaries to know the cost in advance. Some Part C plans allow beneficiaries to waive the copay for the ER visit altogether if they are admitted to the hospital within 24 hours.
Medicare Advantage beneficiaries should review their policy to see how their plan covers emergency room visits, or speak with a trusted agent for more details.
How Much Does an ER Visit Cost Without Medicare?
The average ER visit cost $1,150 in 2020. Specifically, uninsured people paid an average of $2,188 for one or more visits to the ER that same year, with older people aged 45-64 paying even more, at $2,243. Visiting the ER is primarily so expensive because equipping ERs for round-the-clock medical services requires civic utilities, human resources, and building maintenance. Medicare offers beneficiaries an affordable copayment for emergency medical services.
When to Go to the Emergency Room
Level | Description | Examples |
|---|---|---|
1 | Life-saving intervention needed immediately | Cardiac arrest; Massive blood loss |
2 | Time-critical problem | Cardiac-related chest pain; Asthma attack |
3 | Stable, multiple types of resources required | High fever with cough; abdominal pain |
4 | Stable, one type of resource required | Simple laceration; pain on urination |
5 | Stable, no anticipated resources required | Rash; Prescription refill |
Emergency healthcare professionals use a tiered triage system to treat incoming patients by the severity of their condition. The above table illustrates a range of examples of when to go to the ER, from low-priority injuries or ailments (level 5) to life-threatening conditions (level 1).
The following urgent symptoms always warrant a trip to the ER:
- Chest pain or pressure
- Difficulty breathing or shortness of breath
- Severe abdominal pain or cramping
- Head injury or severe headache
- Seizures or loss of consciousness
- Severe burns or cuts
- Broken bones or dislocated joints
- Severe allergic reactions
- Signs of a stroke or heart attack, such as sudden weakness or numbness on one side of the body, slurred speech, or difficulty seeing
Alternatives For Medicare-covered Care If You Do Not Have an Emergency
In some situations, Medicare beneficiaries may require medical attention but are not in critical condition. If you are not experiencing urgent symptoms but time is still of the essence, you may find the help you need through one of the following Medicare-approved ER alternatives.
Urgent Care Clinics
How Medicare Covers This: Most urgent care clinics accept Medicare for the treatment of non-life-threatening but time-sensitive injuries or illnesses. Once you have met your Part B deductible, you are responsible for 20% of the cost of the urgent care visit. If you have not yet met the deductible, you may be responsible for paying out-of-pocket for this visit. Unlike some ER visits, urgent care clinics do not involve Part A.
Telehealth Services
How Medicare Covers This: Medicare covers 80% of telehealth services under Part B, as routine outpatient medical care. You might seek telehealth services as a Medicare beneficiary if you are experiencing a non-life-threatening illness or condition for which you do not need hands-on treatment, such as an x-ray or stitches. Like other Part B benefits, you must meet your deductible before Medicare pays their portion of this cost.
Medical Doctor Appointment
How Medicare Covers This: Medicare also covers doctor appointments under Part B. In fact, this is the primary reason Part B coverage exists, for beneficiaries to have access to their Medicare-enrolled doctors and local healthcare facilities for occasional illnesses or injuries. As in any case where a coinsurance applies, you must meet your deductible in order for Medicare to pay 80% of this cost.
Retail Clinics
How Medicare Covers This: Medicare covers retail and other walk-in clinics under Part B.
Examples include MinuteClinics inside CVS stores, RediClinics at Rite Aid, and Walmart Health Clinics. This type of care is only suitable for non-life-threatening injuries or illnesses, and Medicare classifies retail clinics as an outpatient medical service. You will owe 20% of the cost if you have met your Part B deductible or 100% if you have not. Care at retail clinics costs less than urgent care, but they do not have the same extended hours.
Putting It All Together
The cost of accessing emergency medical services should never discourage someone from seeking help. This advice applies to everyone, regardless of their age or health status, but is especially relevant to Medicare beneficiaries who may require emergency room visits more frequently than the average person.
Medicare covers emergency services through Part B benefits, which include outpatient medical care. Beneficiaries who meet their Part B deductible owe 20% of ER costs, which includes treatment during their visit to the ER and ambulance transportation. Medicare also covers hospitalizations ordered by ER doctors and related expenses through Part A, should a patient require longer-term inpatient care.